Who should get the swine flu vaccine ?

Vo Thai Son

(In UK) One of Labour's favourite mantras is that being in government is about making the tough decisions. But when it comes to swine flu, a series of choices is approaching that may prove a matter of life and death.

The problem is this. The Government has purchased enough vaccine against this strain of swine flu (H1N1) to treat the entire population – 61 million people – at a cost of £155.4 million. However, by the end of the year, when the second wave of the pandemic is expected to be at its height, we will only have received half of the order. So officials have a decision to make: who gets the vaccine first?

According to the World Health Organisation, frontline health workers are the top priority, followed by the most vulnerable groups. In a paper published yesterday on The Lancet website, researchers urged that pregnant women should be prioritised because, according to reports from the US, they have higher than expected death rates from swine flu. The very young and those with existing medical conditions will also be high up the list.

But the key question – which is said to be preoccupying civil servants at the Department of Health, and their Secretary of State, Andy Burnham – is who comes next. Pensioners are normally a priority for flu vaccines. But they do not seem to be at quite as much risk from H1N1: rates of infection and hospitalisation are surprisingly low, perhaps because of residual immunity to similar strains in the 1950s, perhaps because it is easier to avoid infection if you don't have to go to work.

This leads us into the kind of value judgments that make us uncomfortable. Some ethicists argue that the fairest means of distribution, after taking care of the most vulnerable, is a lottery. Professor Robert Dingwall, who sits on the Committee on Ethical Aspects of Pandemic Influenza, points out that it is illegal to discriminate in terms of age, or usefulness to society. In other words, a healthy pensioner cannot claim priority over a healthy teenager, unless there is evidence that pensioners are at greater risk – but nor can the authorities choose to vaccinate that teenager on the grounds that he has a longer life ahead, or will make a greater contribution to the economy.

There are also possible problems with the vaccine. In 1976, an outbreak of another strain of swine flu at a US military base prompted a panicked attempt to immunise the entire American population. Before the programme was abandoned, 40 million people had received the jab – several hundred of whom developed Guillain-Barré syndrome, a rare neurological condition that causes muscle weakness or paralysis.

As a result, more than 30 people died, compared to just one soldier killed by swine flu.

The risk of such side effects is less today, given that the "template" for the new vaccine has been tested using a different strain. There is also more reason to be alarmed, given the rapid spread of the outbreak. Yet the World Health Organisation has warned of the dangers of rushing vaccines to market. Already, the British and US governments have had to absolve manufacturers from liability. And even if there are no undiscovered side effects, what happens if – as with MMR – a belief arises that a safe vaccine is risky? If a parent refuses to vaccinate their child, should the state have the right to enforce it in order to protect the child, or others they might infect?

These questions have no easy answer – but the Government must address them. There have already been deaths from swine flu. But the decisions made in the coming weeks about who gets the vaccine, and in what order, may save – or endanger – many more. We can expect a few more sleepless nights in the corridors of power.
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